Tackling Global Health: Women and Water

Below is my column, online this week, for the Rwanda Edition of the Independent magazine.

Tackling Global Health: Women and Water

Published online November 29, 2011

History suggests that women and water are essential in conquering the developing world’s health challenges

World Toilet Day came and went without much fanfare. In between using the toilet yourself, you probably missed it. Talking about toilets is not sexy, and discussing water and sanitation is probably not at the top of your list, but it should be. Women and water, specifically clean water, have been responsible for major improvements in health in the developed world and hold enormous potential for tackling its health challenges.

At the turn of the 20th century, some of the top killers in the United States included tuberculosis, pneumonia, typhoid, meningitis, influenza, and diarrhea (for children under two years of age).  In 1900, approximately one in six American babies would not live to see their first birthday, according to one recent estimate. In just thirty years, however, infant deaths in the U.S. had fallen by more than half, to an estimated 70 deaths per 1000, approximately equivalent to infant mortality rates in Rwanda today. What accounts for this tremendous improvement in child health in America?

It is tempting to suggest that new medical technologies led to massive improvements in health, and particularly child health. In the course of the 20th century we saw an unprecedented period of medical innovation, which ultimately led to the widespread availability of life-saving vaccines, antibiotics, and other medical technologies we take for granted today. But what is remarkable is that the decline in mortality, particularly due to infectious disease, occurred before the spread, and often before the invention, of these technologies.

Deaths due to scarlet fever had fallen to nearly zero by the time penicillin, a common antibiotic today, was invented in 1946. Similarly, deaths from typhoid and tuberculosis fell dramatically before the introduction of antibiotics to treat these bacterial infections were invented in 1948 and 1950, respectively. It was not until 1963 that a vaccine to prevent measles was invented, by which point very few people died of measles in the U.S. Most of the decline in mortality from infectious diseases in the U.S. occurred before the introduction of medical technology used to prevent or treat them.

So what accounts for the decline in mortality due to infectious disease? To a large extent, women and water. Recent research by Grant Miller of Stanford University finds that women’s suffrage in the U.S. directly contributed to increases in public health spending in the 1920s. Much of this health spending went toward public campaigns to improve hygiene. Around 20,000 child deaths were averted as better hygiene prevented the spread of deadly infectious diseases. Miller argues that legislators anticipated women support of public funding for health, and voted for more progressive public reforms as soon as they won the right to vote.

In related work, Miller and economist David Cutler find that improvements in water systems in the U.S. between 1900 and 1940, specifically filtration and chlorination, contributed to three quarters of the decline in infant mortality and two thirds of the decline in child mortality during this period. Waterborne diseases were responsible for a large proportion of deaths during this time, particularly in U.S. cities, and water treatment and filtration led to a major decline in these waterborne illnesses.

Today, over one billion people around the world do not have access to clean water, and over two billion to not have access to sanitation facilities. In Rwanda, only an estimated 23 percent of the population had access to adequate sanitation in 2006, and in Uganda only 33 percent. In Uganda’s capital city, Kampala, only eight percent of homes are connected to a sewage line. A greater proportion of the population have access to clean water—64 percent in Uganda and 65 percent in Rwanda—but nearly one third of the population continues to consume unsafe water on a daily basis.

Much of the emphasis on public health today focuses on supply-side factors – on health care rather than health, on curative rather than preventive treatments, on hospitals rather than homes. But history suggests that the greatest improvements in health have taken place within the home, with a focus on preventing infectious disease rather than treating it. Women play a key role in this process. Women are more likely to be in charge of feeding children and ensuring their homes have clean water and adequate sanitation, and some research suggests women tend to place greater value on child welfare (this is why cash transfers programs often target women in the household, rather than men). As we have seen in the U.S., women voters can have a profound impact on legislator behavior and consequently, public policy.

Survey evidence from the Afrobarometer suggests that health is a major concern for ordinary Ugandans, and populations throughout sub-Saharan Africa. In 2011, 26 percent of Ugandans said that “improving public services such as education and health” was their top concern, and 50 percent said that health was among the “most important problems facing this country that the forthcoming 2011 elections should address,” and ranked health higher than any of the thirty-odd other policy issues. Whether legislators act on the policy preferences of their constituents is another matter altogether. Nevertheless, the potential of the electorate, and women in particular, to influence public policy should be taken seriously, especially with regard to health.

A focus on hygiene may be as efficacious, if not more so, than the antibiotics and antimalarial drugs that are ubiquitous in public health today. The difference between 1920s America and the developing world in 2011 is that we are not forced today to rely on prevention of disease, because the momentous gains in medical technology allow us to treat the most common causes of death and disability. But this new technology should not become a crutch, and we should not forget the tremendous gains in population health that can be made by focusing on hygiene rather than a vaccine. Toilets may not be sexy, but life without adequate sanitation just stinks.

Beyond the State: Letters from Gulu

Apologies for the extremely sparse posting of late. I have just returned from a trip to Central America, including Belize, Honduras, and Mexico, which I’ll post more about soon. In the meantime, I’d like to share the first edition of a weekly column I began writing for the Independent (Rwanda edition) three weeks ago. I’ll be posting these weekly after they are published online. I look forward to your comments and feedback.

Beyond the state: letters from Gulu

Published online November 23, 2011

Health care, education, basic infrastructure, and security are some of the services the modern state seeks to provide. The success of states in delivering these goods to their far-flung populations, especially in the midst of conflict or under severe resource constraints, is quite variable. In recent years, for example, Rwanda has been lauded for implementing a health insurance scheme that covers all Rwandans and offers them a range of health services, while the reach of the state in countries like the Democratic Republic of Congo or South Sudan is much more limited. While there are important lessons to be learned from the success of the Rwandan state, which has proven itself unusually efficacious in a number of sectors, it is all too easy to overlook the ways in which information and innovation flow alongside the state, and often in spite of state failures. Tremendous opportunity lies beyond the state.

I recently unearthed letters given to me in mid-2005 by a group of primary school students in Gulu, northern Uganda’s largest city, illustrating this point. At the time, to cross Karuma Falls, where the Nile cuts the land like a scythe, was to enter a world far removed from political drama unfolding in Kampala. While Ugandan President Museveni was jostling for the removal of term limits in the capital, the terror of the Lord’s Resistance Army (LRA) in northern Uganda was still unfolding, though nearing its final days. The river dividing north from south might as well have been an ocean.

The reach and strength of the state was limited. Getting to Gulu from the capital carried its risks – tarmac fell away at the edges of the road much of the way from Kampala to Karuma, rebels lingered somewhere north of the Nile, and reaching the environs beyond Gulu was an even greater challenge. The state could not guarantee security, much less provide quality public services. Then Prime Minister, Apolo Nsibambi, in charge of public sector management, did not even set foot in the north until the mid 2000s, more than five years into his term.

When I first received the letters, I was struck by the violent images many of the children in Gulu could portray with a couple of pens and a piece of paper. Looking back, however, more striking than these images are what these youngsters wrote. “Too many children one after the other”, wrote a young boy named Geoffrey. “If a woman is not allowed to rest between children, her reproductive system can be harmfully affected, and her children will not be properly cared for”. Another, Solomon, carefully printed Ghanaian Nobel laureate Raphael Armattoe’s poem, “The Lonely Soul”, word for word. Others wrote about the effect of AIDS on their community, and a young boy named Kenneth drew a picture of “Cent 50”, the American rapper.

These letters illustrate not the failure of the Ugandan state in the north, which had evidently been unwilling or unable to stop the marauding LRA for nearly twenty years, but rather the porous nature of society, and the tremendous opportunities that lie outside the state. These students demonstrate not the dismal quality of Uganda’s educational system in an insecure region, but rather their ability to utilize the resources at their young fingertips. At ages seven to ten, they shared information about child spacing, antenatal care, infertility, the spread of infectious disease, poetry, and American pop culture. Through what channels did they initially access this information? Through school and formal state structures? Possibly, though these are likely to be only part of the story. How can we use these channels, whatever they may be, to further promote innovation and the spread of information?

Our approaches to improving public health and education have often focused on things we can touch and see – a health center, a new classroom, an operating table, a chalkboard – but ignored the social networks and flow of information that do not respect administrative boundaries and are not tied to specific politicians and policies. This bias is in part due to the fact that physical infrastructure is highly visible, and as such, plays an important role in politics. It is much harder to see the networks of common knowledge than it is to see the building of walls. It is easy to undervalue and difficult to use that which we cannot see, at least politically. We tend to privilege infrastructure over information.

How do we take advantage of the vibrant flow of information today? How can we better understand the channels through which it flows – through communities, families, churches, mosques, media, and even music? The state is not the only, or even primary, conduit of knowledge with the potential to improve health, for example. The formal structures of the state and public service provision often seem to fail us – absenteeism among civil servants, rampant corruption, poor policy implementation – but the social structures that connect society have the potential to fill in the gaps.

What is remarkable is not how far we have to go in ensuring a minimum standard of living, which can seem like a daunting journey, but how far we have come, even in the midst of conflict and severe resource constraints. The state can and should play an important and perhaps guiding role in providing public services, but we should also try to understand and take advantage of the opportunities to improve health, education, and other social services already at our fingertips.

Childhood vaccination in sub-Saharan Africa

First of all, if you are in Kampala and interested in health, don’t miss the health journalism conference hosted by the Health Journalists Network in Uganda taking place today at Hotel Africana. Follow HEJNU on twitter for live updates here.

Since I am very far from Kampala, I have been spending time with health data instead. Today I was looking at immunization rates over time in sub-Saharan African countries. The colorful fruits of my labor, looking at measles, polio, and BCG (TB) are below. Each colored line represents a country:


Polio (three shots):



What can we make of these graphs? Well, it looks like measles vaccination rates tend to get “stuck” somewhere around 80% of coverage. Meanwhile, BCG coverage rates hit near 100% by the late 1980s in many countries. Polio has less clear patterns. Why is this? Is it a data problem? I’m not sure, but I’d like to find out.